Provider Demographics
NPI:1114587664
Name:GUSTAFSON, SUZE
Entity type:Individual
Prefix:
First Name:SUZE
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5914 W CARGO CIR
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-8235
Mailing Address - Country:US
Mailing Address - Phone:801-694-0591
Mailing Address - Fax:
Practice Address - Street 1:515 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2142
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4946
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician